Advanced Nursing Research (Demographic tool for EBP project)

1. Are you male or female?

1. Male

2. Female

2. Do you consider yourself Hispanic or Latino/Latina?

1. Yes

2. No

3. What race do you consider yourself to be? Please select one or more of the following:

1. White

2. Black/African American 3. American Indian/Alaska Native

4. Asian 5. Hawaiian Native/Pacific Islander

6. Some other race

(specify): ___________________

4. What is your primary language?

1. English

2. Spanish 3. Some other language

(specify): ______________

5. What is your date of birth?

__ __ / __ __ / __ __ __ __ Mo Day Year

6. Which of the following educational credentials do you have (check all that apply):

a. A high school diploma

b. A GED certificate c. An Associate’s degree d. A technical credential or degree

e. A Bachelor’s degree f. A Master’s degree g. Another advanced degree

7. What is your current employment status?

1. Working for pay at a job or business 2. Looking for work, not currently employed 3. Not currently working and not looking for work

(Specify): ________________

(Specify): ________________

8. In 2006, what was your total family income from all sources? Was it:

1. Less than $25,000, 2. $25,000 to $49,999, 3. $50,000 to $100,000, or

4. More than $100.000?

9. What is your current marital status?

a. Are you currently married or unmarried?

· Married (SKIP TO b)

· Unmarried (SKIP TO c)

b. If married, are you and your spouse currently living together or living separately?

· Living together (SKIP OUT)

· Living separately (SKIP TO e)

c. If not married, have you ever been married?

· Yes (SKIP TO d)

· No (SKIP TO e)

d. Are you widowed or divorced?

· Widowed

· Divorced

e. Are you currently living with a partner, boyfriend, or girlfriend as married?

· Yes

· No

10. How many children do you have? (specify)

______ Biologic or adopted children

______ Step children ______ Foster children

11. How many children with muscular dystrophy do you have? (specify) ______________________

12. How old is/are your child/children with muscular dystrophy? (specify) ______________________

13. At what age was your child with muscular dystrophy first assessed by a primary care provider? (specify)

______________________

14. How much of the care, roughly, do you provide to your child with muscular dystrophy?

1. 0-24%

2. 25-49%

3. 50-74%

4. 75-99%

5. 100%

15. How would you rate your health?

1. Excellent

2. Very good

3. Good 4. Fair 5. Poor

16. Have you ever been diagnosed with one of the following disorders (select all that apply):

1. Bipolar disorder 2. Schizophrenia 3. Dissociative Identity Disorder (Multiple Personality Disorder)

4. Physical addiction (alcohol, drugs)

5. None of the above

17. Does anyone in your family or household have an illness or disability that demands a lot of your attention and makes it hard for you to work or go to school?

1. Yes

2. No